Diane R. asked this question via our latest website survey, and it’s a good one. With all the hype about prevention, it makes sense for us to back it up! First, however, I’d like to cover what prevention is and put it into context.

It’s no secret that in Canada and many other places in the world, our response to homelessness consists mostly of emergency services – shelters, makeshift drop-in centres, etc. While emergency services will always be necessary because, well, things happen, they are not a strategic solution. If homelessness were a disease, emergency services would be akin to a symptom-treating medication – important yes, but it doesn’t really cure the disease; it just manages it. In the words of the authors of the State of Homelessness in Canada 2014 report: “For years we have been investing in a response to homelessness that, while meeting the immediate needs of people in crisis, has arguably had no impact in reducing the scale and scope of the problem.”

A prevention-based approach to homelessness simply aims to keep people from becoming homeless in the first place. The question becomes not “how can we help people experiencing homelessness” but “what can we do to keep people housed?”

Kinds of prevention

Primary prevention – works to mitigate risks and usually targets entire communities, and can include information campaigns; education programs; anti- violence, racism and poverty activism; and early childhood supports.

Secondary prevention – identifies and addresses problems in their early stages. In homelessness, this would include efforts to help people keep their housing or find new housing quickly, including initiatives like rent banks, emergency assistance with utility and other bills, landlord-tenant mediation, and family mediation (includes many services that aim to avoid eviction, which agencies have reported as being successful).

Tertiary prevention – aims to slow the progression of a problem and/or reduce its likelihood of recurring. Regarding homelessness, this kind of initiative focuses on achieving housing stability. When implemented well, Housing First is an example of tertiary prevention.

But does homelessness prevention work?

In a 2006 report, Burt, Pearson and Montgomery wrote: “Researchers (Lindblom 1997, Shinn, Baumohl, and Hopper, 2001) have concluded that strong evidence is still lacking that homelessness prevention efforts are effective, but the bulk of their criticism has to do with targeting and inefficiency, not with the underlying effectiveness of different activities.” The authors outlined four main areas for successful prevention strategies:

ability to target well (includes sharing information across agencies)

community is motivated to create change

resources are maximized (private and public collaboration)

has direction, sustainability, control and feedback

There is a growing body of research that supports Housing First, which aims to include all the aforementioned elements. Of the 1,000 participants in the At Home/Chez Soi study, 80% of people who received Housing First services remained housed after the first year. Additionally:

For many, use of health services declined as health improved. Involvement with the law declined as well. An important focus of the recovery orientation of Housing First is social and community engagement; many people were helped to make new linkages and to develop a stronger sense of self.

In Housing First in Canada: Supporting Communities to End Homelessness, the authors discuss eight case studies of Housing First programs across Canada, concluding the intervention is scalable and successful. But, as the authors note, it will take much more than change within the homelessness sector to truly address homelessness:

At the end of the day, the scalability of Housing First may depend on there being an adequate supply of affordable, safe housing, or on there being robust programs of rent supplements to enable housing people in market housing. Rent supplements address the issue of affordability within a tight rental market without necessitating the development and construction of new housing. Even in communities like Hamilton, which doesn’t have as tight of a market, the use of rental supplements has been necessary to make Housing First work.

No one strategy, program or solution type will ever end homelessness without simply increasing the availability of affordable housing. As Gaetz, Gulliver-Garcia and Richter (2014) wrote in The State of Homelessness in Canada, we need national, and cross-sector support in not just ending homelessness, but preventing it in the first place.

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

This week’s infographic, which appeared in the United Way Saskatoon & Area report, takes a look at the successes of the Journey Home program in Saskatoon. The program focuses on providing housing to Saskatoon’s most vulnerable citizens, many of whom have experienced chronic homelessness.

The Journey Home program utilizes the Housing First approach to ending homelessness. The term Housing First is used to refer to programs that combine immediate access to permanent housing with wrap-around supports. Immediate access to permanent housing means no housing readiness requirements, in contrast to ‘treatment first’ approaches. The presence of supports is an essential component of any Housing First approach. Housing First programs, including Journey Home, typically involve three kinds of supports:

1) Housing supports help people obtain and maintain permanent housing;

2) Clinical supports designed to enhance physical and mental health of the client; and

3) Complementary supports intended to help individuals and families improve their quality of life, integrate into communities and potentially achieve self-sufficiency.

When people have a home, they spend less time in hospitals, police custody and shelters. The Year 1 report for the project states that Journey Home showed a social return on investment of $2.23 dollars for every $1 invested. Inappropriate usage of public system services - like emergency room visits, ambulances rides, police detention and even incarceration - showed an 82% drop post Housing First.

United Way hopes to expand on the Journey Home program. They have a goal to create sustainable housing for the 100 most vulnerable, chronically homeless people in their community over the next three years.

Are there other examples of Housing First initiatives?

Absolutely, there are numerous examples of successful applications of Housing First across Canada. These applications are tailored to the needs of local communities and populations. In British Columbia, the Streets to Homes project in Victoria demonstrates how large-city programs can be adapted to meet the needs of smaller communities. In Alberta, Nikhik Housing First/Homeward Trust highlights what agencies can do to integrate Aboriginal culture into a program. In Ontario, the Transitions to Home project in Hamilton provides a great example of how partnerships with police services can help identify individuals with high needs.

The At Home/Chez Soi study, conducted by the Mental Health Commission of Canada examined Housing First as a means for ending homelessness for individuals living with mental illness. The project followed over 2,000 participants over a two-year period across Canada. Demonstration sites included Vancouver, Winnipeg, Toronto, Montréal and Moncton. Throughout the course of the trial, Housing First was shown to be a “cost-efficient, effective and humane solution to homelessness in Canada”

Housing First trials have also been carried out in the United States, as well as Europe. Today, Housing First is recognized as a best practice for agencies and governments across the world in the fight against chronic homelessness.

Case management refers to a collaborative and planned approach to ensuring that a person who experiences homelessness gets the services and supports they need to move forward with their lives. Originating from the mental health and addictions sector, case management can be used more broadly to support anyone experiencing homelessness. It is a comprehensive and strategic form of service provision whereby a case worker assesses the needs of the client (and potentially their family) and, where appropriate, arranges, coordinates and advocates for delivery and access to a range of programs and services designed to meet the individual’s needs. The National Case Management Network of Canada (NCMN) defines case management as a:

“collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. Case management supports the client’s achievement of safe, realistic, and reasonable goals within a complex health, social, and fiscal environment.” (National Case Management Network of Canada, 2009: 7)

A client-centered case management approach ensures that the person who has experienced homelessness has a major say in identifying goals and service needs, and that there is shared accountability. The goal of case management is to empower people, draw on their strengths and capabilities, and promote an improved quality of life by facilitating timely access to the necessary supports, thus reducing the risk of homelessness and/or enhancing housing stability.

Case management, well established in social work and health care, has many different approaches and practices. Case management can be short term (as in Critical Time Intervention) or long term and ongoing, dependent upon an identified need for crisis intervention related to problematic transitions, or for supports around chronic conditions. Critical Time Intervention (CTI) models are key to early intervention practice in that they are designed to prevent recurrent homelessness and help people transition to independence. This is achieved through:

“strengthening the individual’s long-term ties to services, family, and friends; and by providing emotional and practical support during the critical time of transition. An important aspect of CTI is that post-discharge services are delivered by workers who have established relationships with patients during their institutional stay.” (Critical Time Intervention Website)

Individuals with more complex, severe and persistent health, mental health and addictions challenges may require more intensive case management through Assertive Community Treatment (ACT) teams. In the ACT model, a multidisciplinary team from the community where the individual lives (rather than in an office-based practice or institutional setting) provides case management. The team involves psychiatrists, family physicians, social workers, nurses, occupational therapists, vocational specialists, peer support workers, etc., and is available to the patient/client 24 hour a day, 7 days a week.

A case management approach, then, necessarily works best within a system of care, where links are made to necessary services and supports, based on identified client need. That is, once a person becomes homeless, or is identified as being at risk, they are not simply unleashed into the emergency services sector. An intake process is followed, risks are identified, goals are established and plans are put in place. Individuals in need, therefore become ‘clients’ not of specific agencies, per se, but rather, of the sector. They are supported from the moment they are identified as (potentially) homeless, right through to the solution stage, and then after they have secured housing.

Case management, of course, requires a willingness on the part of the individual to participate, and development of a potentially therapeutic relationship may take time. When people become homeless and have very weak links or engagement with homelessness services, schools or other supports, and are only accessed through outreach and/or day programs, a period of relationship and trust building may be required before case management can be usefully implemented.

In reviewing case management as a key component to ending homelessness, Milaney identified it as a strengths-based team approach with six key dimensions:

Collaboration and cooperation – a true team approach, involving several people with different backgrounds, skills and areas of expertise;

Right matching of services – person-centered and based on the complexity of need;

Contextual case management – Interventions must appropriately take account of age, ability, culture, gender and sexual orientation. In addition, an understanding of broader structural factors and personal history (of violence, sexual abuse or assault, for instance) must underline strategies and mode of engagement;

The right kind of engagement – Building a strong relationship based on respectful encounters, openness, listening skills, non-judgmental attitudes and advocacy;

Coordinated and well-managed system – Integrating the intervention into the broader system of care; and

Evaluation for success – The ongoing and consistent assessment of case managed supports.

There are a number of useful resources to help service providers deliver case management in the homelessness sector. The Calgary Homeless Foundation has developed a report called “Dimensions of Promising Practice for Case Managed Supports in Ending Homelessness”. In Australia, the government has a dedicated website with a large number of resources for doing case management with people who have experienced homelessness. Finally, the National Alliance to End Homelessness also has a number of resources dedicated to this topic.

While seniors aren’t a majority in the homeless population, “there are many whose social marginality, lack of financial resources, or chronic ill health causes them to be seriously at risk of homelessness” (Robertson & Greenblatt, 1992). In Canada, these numbers are increasing. In 2013, there were four times as many seniors experiencing homelessness in Toronto as there was in 2009. Despite Canada having low old-age poverty rates in comparison to other G20 countries, the OECD reports that it increased while other countries’ rates fell.

Causes of homelessness in old age

The National Coalition for the Homeless (2009) cited “poverty and the declining availability of affordable housing among certain segments of the aging” as primary causes of homelessness. Physical and mental health issues, social marginalization/lack of social support and loss of family/caregivers are also often among cited causes.

Though the factors that lead to homelessness are the same for seniors as they are for anyone (a mix of structural, systemic and individual/social), there are some gendered differences in how seniors become homeless. A 2004 Toronto study found that older women are more likely to become homeless due to primarily family-related crises, while older men tend to become homeless due to primarily a lack of employment.

The 2010 OECD report also highlights these differences. Senior women are more likely to have worked part-time, low-wage and/or temporary jobs – which can lead to poverty and homelessness. This especially affects senior women who are separated or divorced.

Another issue cited by the OECD is that seniors in Canada depend more heavily on private capital (assets, private pensions, etc.) to live than most other OECD countries. This leaves all low-income seniors vulnerable, as they are less likely to have such resources.

Isolation and sudden changes in circumstances (such as illness) are also contributors to senior homelessness. With such a wide array of causes, it is impossible to identify pathways to senior homelessness as being clear-cut.

Risks of being homeless in old age

Older people experiencing homeless are in what Kellogg and Horn (2013) call “double jeopardy:”

Aged persons who are isolated, live alone, and lack economic stability and family or social supports are at great risk for becoming homeless. Precipitating factors may include death of a spouse or a caregiver who provided support, job loss, familial estrangement, domestic violence, and mental illness. Once housing is lost, lack of general resources, lack of social supports, and declining health make it extremely difficult for low-income elderly men and women to relocate into other adequate housing…Not only do they face all of the problems that homeless people face regardless of age but they also encounter the problems that elderly people face regardless of housing status.

“Almost 70 percent of older homeless people reported first becoming homeless between the ages of 41 and 60.

Most of the older adults currently at risk for homelessness had been homeless at least one time in their lives.

Almost 60% of the chronic homeless rated their health as poor or fair; almost 50% of the new homeless rated their health as good, very good, or excellent. In the general population, 80% of older adults rate their health as excellent.

According to the SF-12 (a standardized measure of health status), homeless older adults are physically older than their chronological age, and are in worse physical health than the general older population.”

Addressing senior homelessness

One Ontario case study of 129 service users (who were older and experiencing homelessness) “…confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers.” The study also underscored larger systemic failures that act as barriers to the program, which included “limited housing options available; limited income supports; and lack of coordinated, accessible community health and support services.”

Woolrych and Gibson made some recommendations on how we can work towards preventing and addressing senior homelessness:

Funding based on needs rather than age (young people are frequently targeted for employment and substance use programs, but these do not benefit seniors, who look at their future differently)

Providing affordable housing that meets seniors’ needs: supported living services, fulfills sense of purpose and community – HEARTH is an example of successful service-enriched housing

Not all services or solutions will work for all seniors experiencing homelessness. One population that requires additional consideration is Aboriginal seniors, who must cope with the challenges of aging as well as the ongoing legacy of colonization and racism in this country. Beatty and Berdahl (2011) recommend establishing long-term care facilities in major prairie cities and on reserves for Aboriginal seniors; as well as funding initiatives for Aboriginal caregivers. As I wrote before in a blog post about senior women, “more publicly funded long-term care for all Canadian seniors—like those created in Sweden, Denmark, and Iceland—would be beneficial for all, and would help relieve some of the financial stress on our seniors.”

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

This week’s infographic, created by World Hepatitis Day, takes a look at using harm reduction as a tool to reduce the spread of hepatitis. Hepatitis is a disease characterized by the presence of inflammatory cells in the liver. While it is possible for hepatitis to occur with limited, and even no symptoms, hepatitis often leads to other diseases (ex: jaundice). The term harm reduction can be defined as “an approach or strategy aimed at reducing the risks and harmful effects associated with substance abuse and addictive behaviours for the individual, the community and society as a whole.”

The infographic states that globally 67% of people who inject drugs are infected with hepatitis. Upwards of 10 million people who inject drugs worldwide have hepatitis B or C. Vaccination rates of hepatitis B among people who inject drugs are lower than in the general population. The infographic also states that stigma and discrimination of people who use drugs stop them from getting tested and treated. Individuals and families that are living in homelessness are a perfect example of individuals who face stigma and discrimination in how health services are both structured and delivered.

In Toronto, homeless individuals are 29 times more likely to have the hepatitis C virus compared to members of the general population. Over the long-term, hepatitis C can lead to long-term kidney failure and kidney cancer. Hepatitis C is primarily spread through intravenous drug use and the sharing of needles. Other homeless populations across Canada are also likely to have higher rates of hepatitis B and C compared to the general population.

Harm Reduction

Rather than condemning substance use, a harm reduction approach is focused on reducing the risks associated with using drugs. The approach is nonjudgmental, and is meant to “meet people where they are at”. Programs built into such an approach may include the facilitation of peer support groups for drug users, needle distribution as well as supervised injection sites.

Insite, located in the Downtown Eastside neighbourhood of Vancouver and the only legalized supervised drug injection site in North America, is an example of a program that takes such an approach. The neighbourhood has been considered the centre of an injection drug epidemic, and was reported to be home to 4700 injection drug users in 2000. The results of the Insite program, which opened in 2003, have been largely positive. There have been zero overdose death reported at the facility, a 78% decrease in new reported cases of HIV among people who inject drugs in the local area between 2002-2011 and a 55% decrease in new reported cases of Hepatitis C over the same time period.

There is a great deal of evidence that speaks to the effectiveness of harm reduction, both nationally and internationally. Programs and communities in Canada have been successful in reducing health risks (ex: reducing rate of infection for Hepatitis) for community members through the adoption of a harm reduction approach. However, we continue to allow misunderstandings about this innovative strategy, and misplaced fear and prejudice against drug users, to act as a barrier against wider adoption of harm reduction.